RunSmart - The Book

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"Get your facts first,
then you can distort them as much as you please." (Mark Twain)

If the American public
knew what was going on in the undercurrents of their health care, I
don't think they'd stand for it much longer. Regardless of whether
you have insurance or not, if the average person was a better
consumer of their health care, they would demand accountability. They
would demand results. And they would do so just as they do with any
other free enterprise industry.

First of all, it
doesn't matter whether the care is good (outcomes-driven and
evidence-based) or not, your insurance carrier is likely going to pay
for it. What is currently accepted in our community may not in fact
be a part of any accepted clinical guidelines, or, worse yet, it may
be totally unsupported in the scientific literature. Though we are
finally seeing some examples of “payment for performance”
(something I wrote about here in 2007), the third party payment issue
produces a potential level of mediocrity, whether we like it or not.
Is there any reason to do what is best when you're going to be paid
regardless of what you do?

Second of all, this is
another issue of trust. For years, we have gone on the assumption
that the one person you can trust implicitly in your health care is
your primary care provider. Why not? These gatekeepers are the
revered ones, and thus we believe that what they do for us is in our
best interests. The same is true of specialists like orthopedists.
“Of course they will do what is best for us” ...

And
now, when you add these two issues together, you get our
current system, which for many comes down to dollars and cents. There
is a common phrase - “follow the money trail”. And there is
plenty of evidence to indicate that our trust in the health care
system is being betrayed – regularly. And it goes far beyond simply
“what you practice and how you practice”.

So let's openly
discuss another area of silence in health care: self-referral. We
have laws in place – such as the Stark Laws – that govern
physician self-referral. By law, there is an inherent conflict of
interest to owning your own ancillary services like laboratories,
imaging, and rehab services. With these laws in mind, there is an
interesting game that is played in all of this. Physicians and
chiropractors become “appointed” Medical Directors of these same
services. The party line is that the addition of these services under
one roof makes it more convenient for the patient, or allows the
group practice to “provide the best services under one roof”. Of
course, the concept of “bringing all the best services under one
roof” sounds fabulous – and admittedly, the idealism of the
concept can, at first, overshadow the “gray areas” of service
utilization. In the specific sense of the law, are they
“self-referring”? No.

But this can lead
directly to the over-utilization of these types of services – and
there is plenty of data to support this occurrence. Start with
services such as imaging (x-ray and MRI) that are now being utilized
as a first line of assessment. What is interesting is that in much of
the orthopedic literature (and globally accepted clinical
guidelines), this strategy is unsupported. MRI is over-utilized. The
scientific literature supports this claim.

And if we go one step
further, to rehabilitation services, they are over-utilized as well.
Let's look specifically at the utilization of physical therapy. The
primary care providers and specialists won't necessarily tell you
that you have a right to choose your physical therapist, but, by law,
they must provide this to you. More
often than not, they don't give the patient options for their care.
Of course, most patients simply don't want to go counter to the
trusted authority of their provider, and yes, it sure does seem
convenient from an insurance perspective.

The
reality is that they do refer to a business in which they have a
financial interest. This is why some regulatory bodies mandate that
doctors declare their financial interest with clinics in advance.

Now, the numbers. The
Journal of the American Medical Association reported in 1992 that
patient visits were 39 to 45% higher in physician-owned practices,
and that both gross and net revenues were 30 to 40% higher in the
same physician-owned practices. In 1991, the state of Florida Health
Care Cost Containment Board found that physician-owned physical
therapy clinics provide 62% more patient visits per full time
physical therapist, and 43% more visits for each patient. I have
provided these references below.

Astounding? Yes.

If you are a physical
therapist working in this type of environment, will the physician or
chiropractor ever state “we need to see the patients more often”?
Not in so many words – because that would be illegal. Do they ask
“are we seeing them enough”? Or “could they be getting this or
this as part of their treatment?” or “Do we need to follow up
with them a little longer?”. Yes. And I can say that yes, I have
experienced these “questions” as a PT working within both
physician-owned and chiropractor-owned businesses. It wasn't overt,
but the underlying inference and theme was definitely present.

Do physical
therapist-owned clinics stand to lose dollars because of this? Yes.
There is nationwide data to confirm this, and anti-trust horror
stories that would make your head spin.

So yes, these issues
are alive and well in our own community. The problem isn't just in
someone else's community – it's right here. And it's affecting your
health care – either with costs now, or costs with insurance
premiums down the road.

But if you start to
bring this to the light of day, beware of the power struggle that
will invariably rear it's ugly head. Providers will go so far as to
tell patients that you don't exist (even when patients tell them that
yes, indeed, you do) – and yes, I know this happens. In my own
backyard.

And what do you do if,
heaven forbid, you are injured and now face this reality of having to
be a consumer of your health care? And what if you are a runner that
simply needs to get back to training?